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Welcome to Paediatric Department Ipoh Hospital

This article aims to deal with the most common problems presented by parents in the pharmacy, such as diarrhoea and vomiting, constipation, various respiratory tract infections, parasitic infections and common infectious diseases. In each case the signs, symptoms, possible causes, complications and typical treatments will be addressed.

My child is vomiting and has diarrhoea?
Diarrhoea results in a profound loss of water and possibly dehydration and it is important to ascertain the cause of the diarrhoea before attempting any treatment. Loose frequent stools may simply be due to the excess intake of foods rich in dietary fibre or may be a symptom of an infection, either viral or bacterial. Vomiting may also have many causes and different accompanying symptoms (Table 1). If a child continues to vomit over a six-hour period and diarrhoea, fever or any other worrying symptoms such as earache accopany the vomiting, a doctor should be consulted.

TABLE1. Possible causes of vomiting in babies and children

Accompanying symptoms Common causes
The baby brings up a little milk during or after feeds, but seems content, feeds well and is gaining weight Possetting normal and harmless
The baby of less than 10 weeks vomits forcibly during and immediately after a feed on more than one occasion Possible pyloric stenosis
The baby has a runny or blocked nose, snuffly breathing or a cough A common cold may result in excess mucous being swallowed and this may cause vomiting. A cough may also make a baby vomit
The baby or older child seems un-well and has passed frequent watery stools Possible gastro-enteritis or food poisoning in an older child
  • Consult a doctor immediately
The child seems unwell, looks flushed and feels hot An infection is the most likely cause of the fever and can result in vomiting.
  • Consult a doctor
The child complains of a severe headache on one side of his forehead Possible migraine
The child has abdominal pain around his/her navel and to the lower right side of the groin Possible appendicitis
  • Consult a doctor immediately
The baby is in severe pain and is passing stools that contain blood and mucous. Possible bowel blockage
  • Consult a doctor immediately
The child cannot bend his neck forward without pain and turns away from bright light Possible meningitis
  • Consult a doctor immediately

Diarrhoea and vomiting should always be taken seriously due the risk of dehydration, particularly in babies and small children. In the case of gastro-enteritis in an infant or small child it is better to allow the diarrhoea to continue in order to get rid of the offending organisms and for this reason anti-diarrhoeal medication should not be used. It is how-ever important to give the child frequent, small amounts of liquid added every 10 - 15 minutes to prevent dehydration. A simple formula for rehydration is 1litre of clean water, half a teaspoon of salt and 8 teaspoons of sugar. As a rough guide a child should drink 200ml of liquid per kilogram of body weight in 24 hours while he has diarrhoea. When the nausea and vomiting has passed the child should be given bland foods such as bananas, yoghurt and soups and solids should be introduced slowly. If a baby is being breastfed and suffers with diarrhoea it is advisable to continue breastfeeding.

Is my child constipated?
It is important to remember that constipation is the word used to describe the consistency of stools and not the regularity or frequency of bowel movements. During infancy, constipation is unlikely to occur in breastfed babies and if it occurs in bottle fed babies, it is most likely due to the incorrect use of infant formulas. When babies are given solid foods, constipation may occur due to a lack of fresh fruit and vegetables in the diet. By the age of two or three constipation may occur due to the wilful holding back of stools, particularly in a family focussing strongly on toilet training and regularity. As a guide, if the child is otherwise healthy and happy and experiences no discomfort when going to the toilet and if his stools are not as hard as pebbles, he is not constipated. Furthermore, if the childs stools are hard and dry during a period of illness, particularly if he has a fever or has been vomiting, this is not true constipation. The body compensates for loss of fluid by absorbing water from the stools and the bowel action should return to normal when the illness has passed.

Occasional constipation is not serious and can be avoided by means of a diet rich in fibre. Chronic constipation can be a serious matter because it can cause problems later in life.

My child has a fever?
Normal body temperature range is 36 -37C and anything over 37.7C is regarded as a fever, although the height a temperature reaches is not necessarily an accurate reflection of the seriousness of the illness. A temperature of over 37.7C should always be considered serious, particularly in an infant or small child, as there is a slight risk of febrile convulsions. If a child is suffering from a fever the immediate treatment should be to cool the child down by stripping off most of the clothing and putting the child to bed with only a cool sheet covering them. If the fever is over 40C the child should be sponged down with tepid water and the temperature should be monitored every 5 minutes until the temperature drops to below 38C when sponging should cease. Cold water should never be used for sponging as causes the blood vessels to constrict preventing heat loss and therefor incresing the body temperature. In addition the child should be encouraged to drink small amounts of fluids at regular intervals.

Products such as paracetamol may be used to reduce the temperature. If the temperature does not come down sufficiently with one of these, they may be alternated every 3 hours. Aspirin should not be given to children under the age of 12 years, particularly if the child shows symptoms of chicken pox or influenza as this has been linked to the development of Reyes syndrome.

An elevated temperature in a baby or child is usually as a result of infection and should be referred to a doctor. There is some speculation that teething may cause a fever in some babies but there is no conclusive evidence to support this and it should not be used as a diagnosis without further investigation. If the child shows any other symptoms such as ear ache, stiff neck or diarrhoea a doctor should be consulted immediately.

My child is very miserable, has a fever and is not eating well?
The common cold or influenza could be the cause of these symptoms, although the common cold usually doesnt cause an elevated temperature. If the accompanying symptoms suggest a cold or flu then symptomatic treatment should be sufficient. If the problem persists, it is important to rule out the presence of a secondary bacterial infection in the respiratory tract. The most common secondary infections include sinusitis, tonsillitis and otitis media.

Babies rarely suffer from sinusitis or tonsillitis and these generally occur in children from the age of three. Otitis media is however more common in young children due to the shortness of the eustachian tube and the fact that young children spend a lot of time lying down. This makes it easier for any infection in the nose or throat to spread to the middle ear. Otitis media may also occur as a result of blockage of the eustachian tube by enlarged adenoids which prevent the drainage of mucous and result in a condition known as glue ear.

The possible signs and symptoms for these common infections are summarised in Table 3. A doctor should always be consulted if any of these infections is suspected, particularly tonsillitis, which may result in rheumatic fever or nephritis and otitis media which may cause permanent hearing loss if left untreated. If the infections are bacterial an antibiotic will need to be prescribed for the child.

TABLE 3. Signs and symptoms of sinusitis, tonsillitis and otitis media.

Sinusitis Tonsillitis Otitis media
  • Yellow or green discharge from the nose.
  • Pain over the cheeks.
  • Pain on moving the head.
  • Slight fever.
  • Blocked nose.
  • Sore throat, possibly bad enough to cause difficulty swallowing.
  • Red and enlarged tonsils possibly covered in yellow spots.
  • A temperature of over 38.
  • Swollen glands in the neck.
  • Mouth breathing, snoring and a nasal voice when the adenoids are affected.
  • Unpleasant breath.
  • Severe pain in the ear or in a baby pulling and rubbing of the ear accompanied by crying
  • Temperature of over 39C
  • Vomiting
  • Partial deafness
  • Pussy discharge from the ear

Symptomatic treatments include the use of paracetamol or mefenamic acid to reduce the fever and ease the pain. In the case of sinusitis topical decongestants and inhalants may be used to ease the congestion.

My child has a rash?
A rash may be a symptom of an infection either in the skin or elsewhere or could be an allergic reaction to something on the skin or a reaction to an irritating chemical or due to physical damage.

Systemic rash
Firstly it is important to note where the rash occurs and whether it has spread from one area to another. Also check if the child has a fever which would indicate a systemic infection. Many childhood infectious diseases have a rash as one of their main symptoms, including Chickenpox, German measles and Measles. The symptoms, distinguishing characteristics and possible complications of these diseases are summarised in Table 4.

TABLE 4. Common childhood infectious diseases.

Chickenpox German measles Measles
Incubation period:
17 21 days
Incubation period:
14 21 days
Incubation period:
8 14 days
Typical symptoms:
  • Small blisters appearing in new batches every three to six hours over a period of three to four days, usually starting on the trunk, then spreading to the face, arms and legs and eventually scabbing over.
  • Intense itchiness
  • Headache and fever
Typical symptoms:
  • Rash starts behind the ears before spreading to the forehead and the rest of the body.
  • The rash appears as a large patch of redness as opposed to spots.
  • The rash last about two to three days and is usually accompanied by mild fever and swollen glands in the neck.
Typical symptoms:
  • The first indication is usually common cold symptoms accompanied by a fever and white spots inside the mouth. The childs eyes may also be red and sore.
  • Three to four days later small, brownish-red spots appear behind the ears and merge to form a rash over the face and torso.
Treatment:
Symptomatic treatment with calamine lotion and an anti-pyretic
Treatment:
Symptomatic treatment with an anti-pyretic
Treatment:
Symptomatic treatment an anti-pyretic
Complications:
Possible encephalitis
Complications:
Possible encephalitis
Complications:
Possible otitis media, pneumonia and encephalitis.

Examine the rash to see if it is purpuric, which could indicate a more serious underlying disorder such as meningitis or leukaemia. Purpuric marks can be distinguished by pressing the side of a drinking glass on them if the marks do not blanch and remain visible this indicates purpura. Any purpuric rash should be referred to a doctor for further investigation, particularly if the child has a fever and stiff neck, as this may be a sign of meningococcal septicaemia (Table 5).

TABLE 5. Possible symptoms of meningitis

Meningitis Meningococcal septicaemia
  • Fever as high as 39C
  • Stiff neck
  • Lethargy
  • Headache
  • Inability to tolerate bright light
  • Bulging fontanelle
  • Drowsiness and confusion
  • Vomiting
  • Purple-red rash over most of the body
  • Fever
  • Headache
  • Skin rash of small haemorrhages (purpura)
  • Shock and collapse
  • Stiff neck.

If meningitis is suspected, bend the childs head forwards so that the chin touches the chest and see if there is any stiffness or pain in the neck. If the child is under two, see how he reacts to bright light and check if the fontanelle is bulging. A doctor should be consulted immediately if meningitis is suspected.

Finally it is important to check whether the child has eaten something for the first time, particularly things like shellfish or strawberries or whether the child is taking any medication in order to rule out an allergic reaction.

Localised rash
Localised rashes could be due to conditions such as Eczema or Impetigo or due to skin infestation by Scabies or Ringworm.

Eczema is an allergic condition which produces a very itchy, dry scaly red rash on the face neck and hands and in the creases of the limbs. The most common form of eczema in children is atopic eczema, which usually develops when a baby is about 2 to 3 months old, or when solid foods are introduced. Certain foods, most commonly dairy products, eggs and wheat, and skin irritants such as pet fur and washing powders are among the main causes. It is common for eczema to be followed by other allergic complaints such as hayfever and penicillin sensitivity. It is also quite common for a child with eczema to suffer from asthma. Although most children grow out of eczema by the age of three, the associated allergic conditions remain.

If eczema is suspected it is usually advisable to refer the child to a doctor or dermatologist or they may consult a dietician in order to discuss avoidance of the food groups which usually trigger the condition. Anti-histamines may be used to reduce the itching and allow the child to sleep better and emollient creams may be used topically to ease the dryness of the skin.

Impetigo is a bacterial skin infection that is most often seen around the lips, nose and ears. It is caused by organisms such as staphylococcus and streptococcus that are carried in the nose and on the skin. The rash usually starts as small blisters that break and crust over to become yellow-brown scabs. The condition is most often seen in school going children and is contagious.

If impetigo is suspected it is important to advise the parents to keep the child out of school and to be careful about hygiene at home so that the infection does not spread to the other family members. A doctor should be consulted and usually an antibiotic cream such as Flucloxacillin will be prescribed. In addition, an oral antibiotic and nasal cream may be required to eradicate the infection.

Scabies is a very irritating, itchy skin rash caused by infestation by a tiny mite. The burrowing and egg laying of these mites produces a rash which nearly always affects the hands and fingers, particularly the clefts between the fingers. It may also affect the ankles, feet, toes, elbows and area around the genitals. The lesion on the skin is very typical as the mite burrows along the skin in a linear manner leaving small thread-like grey lines about 5 10cm long. When the eggs hatch they are easily passed to another person by direct contact. Scabies can also be spread through the linen or towels used by the child.

The general treatment for scabies includes the use of Benzyl benzoate  applied over the entire body, except the head and face, after a bath and left to dry. In the case of heavy infestations this treatment should be repeated after 24 hours. Alternatively Lindane wash could be used. All bedding and towels should be washed and ironed with a hot iron and family members should also be treated.

Ringworm is a fungal infection of the skin that shows itself as round reddish or grey scaly patches on the skin or bald patches in the hair. Ringworm is usually contracted from animals, household pets and other infected persons. Treatments include the use of anti-fungal creams such as Miconazole cream for the skin and anti-fungal tablets for the scalp.

Care should be taken to prevent the spread of the fungus and pets should be taken to the vet for treatment. In conclusion, when assessing a sick baby or child always first check for a fever, diarrhoea and vomiting and any sign of bacterial infection. It may be helpful to ask the parent if they have seen any signs of respiratory symptoms such as coughing, difficulty breathing through the nose or ear problems. It is also important to check the nutritional status of the child for any signs of malnutrition or anaemia and finally to check the immunisation status of the child, particularly if an infectious disease is suspected.

REFERENCES:

  1. Greeff, D. Acute diarrhoea needs attention. South African Healthcare workers Assistant. Vol. 1, No. 5. September/October 2001.
  2. Greeff, D. The examination of the sick child. South African Pharmaceutical Journal. Vol. 68, No.
  3. May 2001.
  4. South African Medicines Formulary, Third Edition.
  5. Stoppard, M. Baby and Child Health Care. Struik Publishers 1987.

The problems dealt with in this article represent only a few of the common paediatric problems which healthcare workers are faced with on a daily basis.

It is important to assess each case independently and not to jump to conclusions based on past experiences.

The healthcare worker has a vital role to play in providing advice, symptomatic treatment and appropriate referral.

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